SOAP Note Template

SOAP Note Template

Encounter date: ________________________

Affected person Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____

Purpose for Looking for Well being Care: ______________________________________________

HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Allergy symptoms(Drug/Meals/Latex/Environmental/Natural): ___________________________________

Present notion of Well being: Glorious Good Honest Poor
Previous Medical Historical past
• Main/Persistent Illnesses____________________________________________________
• Trauma/Damage ___________________________________________________________
• Hospitalizations __________________________________________________________

Previous Surgical History___________________________________________________________
Drugs: __________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Household Historical past: ____________________________________________________________

Social historical past:
Lives: Single household Home/Condominium/ with stairs: ___________ Marital Standing:________ Employment Standing: ______ Present/Earlier occupation sort: _________________
Publicity to: ___Smoke____ ETOH ____Recreational Drug Use: __________________
Sexual orientation: _______ Sexual Exercise: ____ Contraception Use: ____________
Household Composition: Household/Mom/Father/Alone: _____________________________
Well being Upkeep
Screening Exams: Mammogram, PSA, Colonoscopy, Pap Smear, And so forth _____
Exposures:
Immunization HX:

Assessment of Programs:
Common:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/feminine genital:
GU:
Neuro:
Musculoskeletal:
Exercise & Train:
Psychosocial:
Derm:
Diet:
Sleep/Relaxation:
LMP:
STI Hx:

Bodily Examination

BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (percentile) _____
Common:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/feminine genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.

Plan:
Differential Diagnoses
1.
2.
three.
Principal Diagnoses
1.
2.
Plan
Prognosis
Diagnostic Testing:
Pharmacological Remedy:
Schooling:
Referrals:
Observe-up:
Anticipatory Steerage:

Prognosis
Diagnostic Testing:
Pharmacological Remedy:
Schooling:
Referrals:
Observe-up:
Anticipatory Steerage:

Signature (with applicable credentials): __________________________________________

Cite present evidenced based mostly guideline(s) used to information care (Obligatory)_______________

DEA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Affected person Title: (Initials)______________________________ Age ___________
Date: _______________
RX ______________________________________
SIG:
Dispense: ___________ Refill: _________________
No Substitution
Signature: _____________________

Template for SOAP Notes

Initials of the affected person: Age: Race: Ethnicity Gender: M/F/Transgender Gender: M/F/Transgender Gender: M/F/Transgender Gender: M/F/

Purpose for Looking for Well being Care: ______________________________________________

HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Allergy symptoms(Drug/Meals/Latex/Environmental/Natural): ___________________________________

Present notion of Well being: Glorious Good Honest Poor

Previous Medical Historical past

• Main/Persistent Illnesses____________________________________________________

• Trauma/Damage ___________________________________________________________

• Hospitalizations __________________________________________________________

Previous Surgical History___________________________________________________________

Drugs: __________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Household Historical past: ____________________________________________________________

Social historical past:

Lives: Single household Home/Condominium/ with stairs: ___________ Marital Standing:________ Employment Standing: ______ Present/Earlier occupation sort: _________________

Publicity to: ___Smoke____ ETOH ____Recreational Drug Use: __________________

Sexual orientation: _______ Sexual Exercise: ____ Contraception Use: ____________

Household Composition: Household/Mom/Father/Alone: _____________________________

Well being Upkeep

Screening Exams: Mammogram, PSA, Colonoscopy, Pap Smear, And so forth _____

Exposures:

Immunization HX:

Assessment of Programs:

Common:

HEENT:

Neck:

Lungs:

Cardiovascular:

Breast:

GI:

Male/feminine genital:

GU:

Neuro:

Musculoskeletal:

Exercise & Train:

Psychosocial
_______________________________________